Notts Healthcare NHSFT Self-harm pathways (used with kind permission)
Different CAMHS across the UK have different structures and teams, but often their services include CAMHS self-harm teams or CAMHS crisis/liaison teams whose role is to undertake urgent hospital/community assessments. The majority of staff in these teams are mental health nurses; this chapter focuses on the nursing skills, sometimes explicit, more often subtle and notoriously difficult to articulate that are used in this context to provide high quality risk and needs assessments to young people who self-harm and present in crisis.
10.2 Definition of Crisis
‘A mental health crisis is a situation which the child, young person, family member, carer or any other person believes requires an immediate response, assistance and/or care from a mental health service, including where there is significant intent or risk of harm to themselves or others. A mental health crisis can have a wide range of underlying causes, diagnoses and triggers, some of which may be longstanding, but which essentially culminate in a deterioration of an individual’s mental state to the point at which they require an immediate response from mental health services’ (NCCMH 2016).
In practice, different services have different ideas about what constitutes a crisis—CAMHS teams are set up for managing mental health crisis with a remit of where appropriate and safe to do so, preventing admission of young people to in-patient psychiatric adolescent units. Implicit in this is the idea that they support young people who otherwise would meet the criteria for admission. Many young people who experience a crisis do not have mental illness and would not meet the criteria threshold for admission and therefore may not be offered a service by mental health crisis teams.
It is acknowledged that underlying reasons and contributing factors to the crisis are often complex and require multi-agency working addressing social, health, educational and other needs. In practice, there is sometimes a risk that young people can fall between gaps in service provision, so nurses in CAMHS crisis teams work holistically, using their advocacy skills, supporting young people to gain access to the services required to meet their needs. In these situations, CAMH nurses utilise their communication skills, clarifying the remit of teams and services and signposting to other organisations as needed.
10.3 Use of Crisis Point
There are many reasons why self-harm gets to a crisis point for young people; this may partly depend on whether it is the first time they have self-harmed or if they have self-harmed before. The first time may present as a crisis point in itself, or for someone who has self-harmed many times before, if they self-harm in a more serious way, e.g. cut themselves more deeply or on a different part of their body, or if their motivation and intent is different than previously, e.g. they feel they cannot take anymore and want to end their life. Sometimes things get to a crisis point very quickly and on other occasions there is a gradual descent into crisis. We should never underestimate the magnitude of what it may be like for young people and parents to access help, especially in a crisis, we need to use our skills of self-reflection to be curious and wonder what it is like to be in each of their ‘particular shoes’.
It is often asked why increasing numbers of young people are self-harming; contributing factors appear to be academic pressures, physical health conditions, bullying, social isolation and social media. Overall the huge amount of pressures that young people feel to fit in, be accepted and ‘get it right’ can feel overwhelming and with social media these pressures are 24/7 with no rest. The CAMH nurse uses their skills to understand this context, and validate their experience in the young person’s world.
They may feel embarrassed, ashamed, guilty and/or scarred—emotions that are difficult to deal with and can result in internal stigma—the young person judging and blaming themselves. They may also experience or anticipate external stigma, discussed further on in this chapter, preventing them from sharing and reaching out for help.
I thought I could manage but it all got too much,
I never thought I would do this
Yesterday was the worst day ever
I just felt I couldn’t go on like that anymore, I just couldn’t bear it
Sometimes, the shock and experience of reaching ‘rock bottom’, i.e. crisis point, together with a high quality risk and needs assessment by the CAMH nurse, where the young person feels listened to and validated, can result in realisation and produce hope and motivation for positive change.
All of this is in the context of adolescent development, a time when young people are still developing their problem-solving skills, they do not have the benefit of vast life experience helping them through complex, painful, social situations. Some more than others may have a tendency to be impulsive, experience rapid mood changes and find it hard to tolerate high levels of distress.
Sometimes young people and parents tell us they have been trying to access help for some time prior to the situation reaching a crisis point and they have not felt listened to, taken seriously or referred to services they feel could help.
Once a young person is in crisis, if they have not received a service before, they can feel a sense of relief and use the opportunity to off-load the difficulties they have been experiencing. If on the other hand they are already known to CAMHS, and have a lead professional and agreed plan, they sometimes find it difficult talking to a different person who they may not have met before, so they can feel frustrated feeling they are ‘going over’ things that other people already know to someone they may not see again.
The CAMH nurse aims to meet the needs of all young people presenting in many different circumstances. They need to use their skills to judge the amount of information needed from a young person, whether to just focus on the immediate presentation, risk and needs or to build up a much bigger narrative, placing the immediate risks and needs in greater context.
As Holly explains:
Whilst the word ‘superficial’ might be a clinical term, using it in front of someone who has self-harmed, or describing someone’s self-harm as superficial when speaking to them, can lead to their self-harm getting even worse. As someone with a long history of self-harm, that word has lead to me feeling my self-harm wasn’t good enough, that it was pathetic and that I was too. It has caused me to self-harm in a more destructive way, needing stitches. The word superficial may seem harmless, but it can be dangerous.
10.4 The Role and Key Skills of CAMH Nurses
The role and skills of mental health nurses are well documented (Callaghan et al. 2009; Callaghan and Gamble 2015) but much less is written about mental health nursing in CAMHS; in fact, concern has been raised about the impact of this lack of professional identity (Baldwin 2008). The paucity of empirical evidence does however leave an opportunity to describe a wealth of practice-based evidence—to create a written record of the key skills used by CAMH nurses day in day out in their work, in this chapter with young people who self-harm in crisis.
Two significant differences between CAMH nurses and other mental health nurses is their role in working with children and young people aged 0–18, therefore spanning a huge developmental range and working with them in the context of their families; parents and siblings. The CAMH nurse uses their skills to adapt to the young person’s developmental stage and abilities and holds in mind and engages with where appropriate all members of the family.
The recent development of a competence framework for self-harm and suicide prevention in children and young people recommends skills and knowledge for professionals across a broad range of backgrounds and experiences (NCCMH 2018). The skills described in this chapter may not be exclusive to CAMH nurses but they are central to, and are the essence of CAMH nursing.
The use of the term care or caring is synonymous with that of mental health nursing and being a mental health nurse. It immediately sets the scene that the mental health nursing role is about the relationship the nurse has with the ‘patient’, their values and beliefs, attitude towards them and the skills of providing a safe, respectful space from which help can be given. Peplau (1952) formed the basis of this is her theoretical model from which mental health nursing has continued to develop.
10.6 Therapeutic Relationship
Following on from Peplau (1952), ‘Decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome, independent of the type of therapy’ (Horvath 2001).
In child and adolescent mental health nursing, the therapeutic relationship that is formed, not only between the nurse and the young person, but also where appropriate with the parents/family is critical both for assessment and on-going work/intervention. This means the skills of the CAMH nurse go beyond the technical ability to apply a theory/model/knowledge, to the skills of relational competence. The relationship is not the background in which change occurs but central to enabling change to occur, using the skills of analysing the interpersonal process as it emerges (Fruggeri 2012).
Thus the ability to use the skills of reflecting in and on action described in Schon’s seminal work is essential (Schön 1983). Reflecting in action is particularly critical in this context, not only due to the need to react to the crisis situation at the time it occurs, including decisions about discharge and safety planning, but in order to ‘see’, ‘experience’, and ‘bear witness’ to the therapeutic relationship that is developing.
Implicit in this is the CAMH nurse bringing ‘themselves’ to the relationship and therefore personal factors playing a key part. It therefore needs to be recognised that sometimes the relationship is not working, i.e. there is not a ‘fit’ and people don’t ‘click’, it doesn’t feel right together. This is important to recognise so, if appropriate, another worker can be found in a helpful, constructive way that will then enable to young person to form a relationship that will enable them to be helped. This may not be possible during the assessment process but it can be acknowledged and planned for future sessions/therapeutic work. This ability and use of skills to ‘get alongside’ young people is invaluable, to engage with them on their level, having a grounded, empathic ‘human’ connection.
10.7 Personal and Professional Boundaries
One of the things that seems to be very important to young people is the nurse’s fine-tuned skills around personal and professional boundaries. Professional in the sense of trustworthy, reliable, excellent communication and interpersonal skills but equally young people tell us they want the nurse to be approachable, friendly, warm, use a sense of humour and be prepared to share appropriate personal experiences—enabling a human connection. The balance to this is maintaining clear professional boundaries, not over-disclosing personal information, not contacting people outside of a work context, not forming relationships that go beyond work in line with our professional code of conduct (NMC 2018). Holly described her positive experiences of the above as CAMH nurses being what she coined as ‘professionally friendly’. Being skilled and comfortable in taking this position seems to be one of the factors that enables mental health nurses in CAMHS to excel in conducting risk and needs assessments and may be one of the reasons why they are the profession of choice in self-harm/crisis/liaison teams.
As well as the therapeutic relationship there are also some overarching philosophies and values critical to high quality nursing care, such as having a person-centred approach (Rogers 1951) which is still as relevant today as it was in the 1950s. More recently, we received a salient reminder of nursing values in the form of the six C’s: Care, Compassion, Competence, Communication, Courage and Commitment (DH 2012).
These are particularly relevant when working with young people who self-harm as they report many examples of experiencing lack of compassion, feeling judged and struggling with both internal and external stigma.
‘Felt stigma, internal stigma or self-stigmatization, refers to the shame and expectation of discrimination that prevents people from talking about their experiences and stops them seeking help. Enacted stigma, external stigma, discrimination, refers to the experience of unfair treatment by others. Felt stigma can be as damaging as enacted stigma since it leads to withdrawal and restriction of social support’ (Gray 2002).
It is ironic that self-harm is often perceived negatively by others as ‘attention seeking’ when for many young people it is hidden and only when they experience the ‘right’ care and compassion do they use their courage to communicate and share with others. It is hoped, with NICE guidelines (2004) feeling necessary to emphasise and promote that people who self-harm should be treated with the same care and respect as others, that young people have since experienced improvements in this area.
10.8 Physical Environment
Whilst the physical environment is important for ‘setting the scene and context’, for helping to make people feel comfortable and more at ease to talk, we may have limited choices about the venue where we see young people, the space and décor of the room. In a hospital setting there may be medical equipment in some rooms and no windows in others; these constraints can be acknowledged as far from ideal by the nurses to the young person and family. Where options are available, making it young person friendly, e.g. therapeutic colours, displaying positive messages and quotes, pictures and relaxed soft furnishing all contributes to creating a therapeutic space or milieu.
Whatever the context and constraints, some things cannot be compromised; the need for a private, confidential space without interruptions is essential. All contact with young people would include an explanation of their rights to confidentiality and the limitations of this where there are concerns about significant harm.
Nurses need to be skilled in understanding the difference between a right to confidentiality and a young person’s wishes. For example, a discussion should always be had with the young person about what information they are happy to share with parents either themselves or via the nurse. It is an error to assume that a person doesn’t want their parents to know anything, when they are often happy for information to be shared if certain information is withheld.
At times of stress, communication can be compromised resulting in young people inaccurately thinking their parents don’t know they self-harm. Discussing the young persons’ reasons for not sharing information is important as often it is because they don’t want to upset their parent or parents, when parents may know already or prefer to know/be less upset that they know.
These are skilled and often delicate conversations that need to be had, and repeated as the therapeutic relationship and trust develops and the work progresses. Just because a young person had a view not to share in the first session does not mean that has not changed over time.
10.10 Risk and Needs Assessment
A risk and needs assessment is the process of using evidence-based knowledge to ask pertinent questions to gather information in order to holistically understand the self-harm in context of the young person, their family, community and world.
In order to have as much consistency as possible across professionals and teams, many services use locally devised risk and needs assessment forms to give standardisation to the questions asked and the information obtained. Such a form should be regularly updated using all available evidence as to the most pertinent information needed. Whist the form is helpful for consistency and as an aide-memoire, it is only as good as the skills of the person using it. The risk and needs assessment process involves using a wide range of high level skills identified in this chapter; these will determine what information the young person chooses to share and thus the accuracy and quality of the understanding.
This is different from a risk assessment tool, which attempts to score and categorise risk, which we are warned against using for reasons stated in the following podcast:
We need to step away from this false notion, fallacy, that we can predict the future, we shouldn’t use risk assessment tools to predict what will happen to someone—as they don’t work. Positive predictive values of risk assessment tools are low—20% of people who went on to repeat were missed by instruments and less than 50% of people rated as high went on to repeat. Most people who die by suicide are assessed as low risk.
Instead, simply ask the young person do they think they are likely to repeat self-harm. Focus on needs based assessment—do our best to address needs, e.g. mental health, relationships, finances, physical health problems. Talking, listening and understanding what’s going on for them may reduce risk by up to 40%—positive experience of empathy and plugging people into the correct services.